Distal Radius Fractures

Author: Mark Vitale

Topic updated on 05/18/13 12:36pm

Introduction

Most common orthopaedic injury with a bimodal distribution
- younger patients - high energy
- older patients - low energy / falls
50% intra-articular
Associated injuries
- DRUJ injuries must be evaluated
- radial styloid fx - indication of higher energy
Osteoporosis
- high incidence of distal radius fractures in women >50
- distal radius fractures are a predictor of subsequent fractures
  - DEXA scan is recommended in woman with a distal radius fracture

Classification

Fernandez: based on mechanism of injury
Frykman: based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fx
Melone: divides intra-articular fxs into 4 types based on displacement
AO: comprehensive but cumbersome
Eponyms: see table for list of commonly used eponyms

Eponyms
Die-punch fxs	A depressed fracture of the lunate fossa of the articular surface of the distal radius
Barton's fx	Fx dislocation of radiocarpal joint with intra-articular fx involving the volar or dorsal lip (volar Barton or dorsal Barton fx)
Chauffer's fx	Radial styloid fx	x
Colles' fx	Low energy, dorsally displaced, extra-articular fx
Smith's fx	Low energy, volar displaced, extra-articular fx

Imaging

Radiographs

View	Measurement	Normal	Acceptable criteria
AP	Radial height	13 mm	<5 mm shortening
	Radial inclination	23 degrees	change <5°
	Articular stepoff	congruous	<2 mm stepoff
LAT	Volar tIlt	11 degrees	dorsal angulation <5° or within 20° of contralateral distal radius

CT scans
- important to evaluate inta-articular involvement and for surgical planning
MRI useful to evaluate for soft tissue injury
- TFCC injuries
- scapholunate ligament injuries (DISI)
- lunotriquetral injuries (VISI)

Treatment

Successful outcomes correlate with
- accuracy of articular reduction
- restoration of anatomic relationships
- early efforts to regain motion of wrist and fingers
Nonoperative
- closed reduction and cast immobilization
  - indications
    - extra-articular
    - <5mm radial shortening
    - dorsal angulation <5° or within 20° of contralateral distal radius
  - technique (see below)
Operative
- surgical fixation (CRPP, External Fixation, ORIF)
  - indications: radiographic findings indicating instability (pre-reduction radiographs best predictor of stability)
    - displaced intra-articular fx
    - volar or dorsal comminution
    - articular margins fxs
    - severe osteoporosis
    - dorsal angulation >5° or >20° of contralateral distal radius
    - >5mm radial shortening
    - comminuted and displaced extra-articular fxs (Smith's fx)
    - progressive loss of volar tilt and loss of radial length following closed reduction and casting
    - associated ulnar styloid fractures do not require fixation

Closed reduction and cast immobilization

Indications
- most extra-articular fxs
Technique
- rehabilitation
  - no significant benefit of physical therapy over home exercises for simple distal radius fractures treated with cast immobilization
Outcomes
- repeat closed reductions have 50% less than satisfactory results
Complications
- acute carpal tunnel syndrome
  - (see complications below)
- EPL rupture
  - (see complications below)

Percutaneous Pinning

Indications
- can maintain sagital length/alignment in extra-articular fxs with stable volar cortex
- cannot maintain length/alignment when unstable or comminuted volar cortex
Techniques
- Kapandji intrafocal technique
- Rayhack technique with arthroscopically assisted reduction
Outcomes
- 82-90% good results if used appropriately

External Fixation

Indications
- alone cannot reliably restore 10 degree palmar tilt
  - therefore usually combined with percutaneous pinning technique or plate fixation
Technical considerations
- relies on ligamentotaxis to maintain reduction
- place radial shaft pins under direct visualization to avoid injury to superficial radial nerve
- nonspanning ex-fix can be useful if large articular fragment
- avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion and ulnar deviation
- limit duration to 8 weeks and perform aggressive OT to maintain digital ROM
Outcomes
- important adjunct with 80-90% good/excellent results
Complications
- malunion/nonunion
- stiffness and decreased grip strength
- pin complications (infections, fx through pin site, skin difficulties)
- neurologic (iatragenic injury to radial sensory nerve, median neuropathy, RSD)

ORIF

Indications
- significant articular displacement (>2mm)
- dorsal and volar Barton fxs
- volar comminution
- metaphyseal-diaphyseal extension
- associated distal ulnar shaft fxs
- die-punch fxs
Technique
- volar plating
  - volar plating preferred over dorsal plating
  - volar plating associated with irritation of both flexor and extensor tendors
    - rupture of FPL is most common with volar plates
    - associated with plate placement distal to watershed area, the most volar margin of the radius closest to the flexor tendons
  - new volar locking plates offer improved support to subchondral bone
- dorsal plating
  - dorsal plating historically associated with extensor tendon irritation and rupture
  - dorsal approach indicated for displaced intra-articular distal radius fracture with dorsal comminution
- other technical considerations
  - can combine with external fixation and PCP
  - bone grafting if complex and comminuted
  - study showed improved results with arthroscopically assisted reduction
  - volar lunate facet fragments may require fragment specific fixation to prevent early post-operative failure

Complications

Median nerve neuropathy (CTS)
- most frequent neurologic complication
- 1-12% in low energy fxs and 30% in high energy fxs
- prevent by avoiding immobilization in excessive wrist flexion
- treat with acute carpal tunnel release for:
  - progressive paresthesias
  - paresthesias do not respond to reduction and last > 24-48 hours
Ulnar nerve neuropathy
- seen with DRUJ injuries
EPL rupture
- nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor pollicis longus tendon
  - extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon.
- treat with transfer of extensor indicis proprius to EPL
Radiocarpal arthrosis (2-30%)
- 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2 mm
- may be nonsymptomatic
Malunion and Nonunion
- Intra-articular malunion
  - treat with revision at > 6 weeks
- Extra-articular angulation malunion
  - treat with opening wedge osteotomy with ORIF and bone grafting
- Radial shortening malunion
  - radial shortening associated with greatest loss of wrist function and degenerative changes in extra-articular fxs
  - treat with ulnar shortening
ECU or EDM entrapment
- entrapment in DRUJ injury
Compartment syndrome
RSD/CRPS
- AAOS 2010 clinical practice guidelines recommend vitamin C supplementation to prevent incidence of RSD postoperatively

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Qbank (13 Questions)

TAG

(OBQ11.273) A 63-year-old female sustained a distal radius and associated ulnar styloid fracture 3 months ago after being involved in a motor vehicle collision. Radiographs obtained at the time of injury are shown in Figure A. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture? Topic

Review Topic

FIGURES: A

1. Worse outcomes on the Mayo wrist score are expected without fixation
2. Chronic distal radioulnar joint instability can be expected to occur without fixation
3. Wrist function depends on the level of ulnar styloid fracture and initial displacement
4. Grip strength and wrist range of motion are improved with fixation
5. There is no adverse effect on wrist function or stability without fixation

PREFERRED RESPONSE ▶

DISCUSSION: An accompanying ulnar styloid fracture in patients with stable fixation of a distal radial fracture has no apparent adverse effect on wrist function or stability of the distal radioulnar joint.

Kim et al evaluated 138 patients who underwent surgical treatment of an unstable distal radial fracture, without fixation of an associated ulnar styloid fracture if present. Postoperative evaluation included measurement of grip strength and wrist range of motion; calculation of the modified Mayo wrist score; as well as testing for instability of the distal radioulnar joint at a mean of 19 postoperatively. They did not find a significant relationship between wrist functional outcomes and ulnar styloid fracture level or the amount of displacement.

af Ekenstam et al performed prospective and randomized study of two different treatments of extraarticular Colles' fracture with a fractured ulnar styloid. In one group, the ulnar styloid was left alone, and in the other group it was transfixed and/or the triangular ligament was repaired after closed reduction of the fractured radius. They concluded that repair of the ulnar styloid complex in extraarticular fractures of the distal radius is not better than conventional treatment.

REFERENCES:

1. Kim JK, Koh YD, Do NH. Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radial fracture? J Bone Joint Surg Am. 2010 Jan;92(1):1-6. PMID:20048089 (Link to Abstract)

2. af Ekenstam F, Jakobsson OP, Wadin K. Repair of the triangular ligament in Colles' fracture. No effect in a prospective randomized study. Acta Orthop Scand.1989 Aug;60(4):393-6. PMID:2683564 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Jan Szatkowski MD,

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TAG

(OBQ10.127) A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. She complains of wrist pain and deformity. On physical exam she has no sensation of the volar thumb, index, and middle finger pads. Radiographs are provided in figure A. Two hours following closed reduction, the deformity is corrected, but the numbness persists and wrist pain is worsening. Which of the following interventions should be taken? Topic

Review Topic

FIGURES: A

1. Evaluation of volar compartment pressures with a needle monitor
2. Follow-up evaluation in 24 hours
3. EMG evaluation of the left upper extremity
4. Percutaneous pin fixation of the fracture
5. Open reduction internal fixation with carpal tunnel release

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph demonstrates a displaced distal radius fracture, and the patient is presenting with neurologic deficits of acute carpal tunnel syndrome. This is a surgical emergency requiring release of the carpal tunnel to prevent permanent dysfunction. Dyer et al performed a retrospective cohort comparison of patients with distal radius fractures. Fracture translation was the most significant risk factor for development of acute carpal tunnel syndrome. Ipsilateral extremity fracture and multi-extremity trauma were trending, but not statistically significant risk factors. In a review article, Schnetzler describes the pathogenesis, evaluation, and treatment of acute carpal tunnel syndrome.

REFERENCES:

1. Dyer G, Lozano-Calderon S, Gannon C, Baratz M, Ring D. Predictors of acute carpal tunnel syndrome associated with fracture of the distal radius. J Hand Surg Am. 2008 Oct;33(8):1309-13 PMID:18929193 (Link to Abstract)

2. Schnetzler KA. Acute carpal tunnel syndrome. J Am Acad Orthop Surg. 2008 May;16(5):276-82. PMID:18460688 (Link to Abstract)

3. Clinical Practice Guideline on the Treatment of Carpal Tunnel Syndrome. Rosemont, IL, American Academy of Orthopaedic Surgeons, September, 2008.

Question Authors:

John Badylak MD,

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TAG

(OBQ09.254) A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Three months after the fracture she reports an acute loss of her ability to extend her thumb. What is the most likely etiology of her new loss of function? Topic

Review Topic

1. Posterior interosseous nerve entrapment
2. Extensor pollicis longus rupture
3. Extensor pollicis longus entrapment
4. Distal radius malunion
5. Intersection syndrome

PREFERRED RESPONSE ▶

DISCUSSION: According to the referenced article by Jupiter and Fernandez, the most common scenario of extensor pollicis longus rupture after a distal radius fracture is when the fracture is non or minimally displaced. The hypothesis is that the rupture happens at an area of relative hypovascularity and healing callus can aggravate this area, leading to a degenerative tear. Hove et al reported an incidence of delayed tendon rupture after distal radius fracture of 0.3 percent. In their series of 18 extensor pollicis longus tendon ruptures, 15 were treated with tendon transfers. They reported good results: nearly 100% patient satisfaction, all patients were able to elevate the thumb to the level of the palm, and full independent index finger movements.

REFERENCES:

1. Jupiter JB, Fernandez DL: Complications following distal radial fractures. J Bone Joint Surg Am 2001;83:1244-1265 PMID:12064104 (Link to Abstract)

2. Hove LM: Delayed rupture of the thumb extensor tendon: A 5-year study of 18 consecutive cases. Acta Orthop Scand 1994;65:199-203 PMID:8197857 (Link to Abstract)

Question Authors:

Ben Taylor MD, Derek Moore,

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(OBQ08.179) A 51-year-old female presents with an acute inability to extend her thumb, four months after she was treated with cast immobilization for a minimally-displaced distal radius fracture. What is the most appropriate treatment at this time? Topic

Review Topic

1. Occupational therapy for strengthening
2. Extensor carpi radialis longus transfer to extensor pollicus longus
3. Extensor pollicis brevis transfer to extensor pollicus longus
4. Extensor indicis proprius transfer to extensor pollicus longus
5. Primary repair of extensor pollicus longus

PREFERRED RESPONSE ▶

DISCUSSION: A rare complication of non-displaced or minimally displaced fractures of the distal radius treated with a cast is a delayed rupture of the extensor pollicis longus (EPL) tendon. The EPL is the primary extensor of the interphalangeal joint of the thumb and also assists with metacarpophalangeal extension. Extensor indicis proprius transfer to the EPL is the most widely used and reported treatment for this condition.

Magnussen et al. reviewed results of EIP transfer following ruptures of the EPL, with 19/21 good results. None of the cases had any loss of independent index finger extension although index extensor strength reduced to half of that of the contralateral side.

Hove et al. reported a similar satisfaction rate following treatment of 15 patients. In his series of 4,400 distal radius fractures treated over a 5 year period, the incidence of delayed tendon rupture following distal radius fracture was 0.3 percent.

REFERENCES:

1. Magnussen PA, Harvey FJ, Tonkin MA. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon. J Bone Joint Surg Br. 1990 Sep;72(5):881-3 PMID:2211775 (Link to Abstract)

2. Hove LM. Delayed rupture of the thumb extensor tendon. A 5-year study of 18 consecutive cases. Acta Orthop Scand. 1994 Apr;65(2):199-203 PMID:8197857 (Link to Abstract)

Question Authors:

Ben Taylor MD, Derek Moore, Michael Hughes MD,

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TAG

(OBQ07.8) Twelve months after open reduction and internal fixation of a comminuted distal radius fracture as seen in Figure A and B, which of the following tendons is at greatest risk of rupture? Topic

Review Topic

FIGURES: A

1. Abductor Pollicis Longus
2. Extensor Pollicis Brevis
3. Extensor Indicis Proprius
4. Flexor Pollicis Brevis
5. Flexor Pollicis Longus

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows a distal radius fracture treated with a volar locked plate. Historically, distal radius fractures treated with dorsal plates are notorious for extensor tendon irritation with some cited rates as high as 50%.

In the reference by Drobetz et al, they reviewed 50 fractures treated with a volar locked plate. They noted that in 6 (12%) of cases that there was rupture of the flexor pollicis longus (FPL) at a mean of 10 months post operatively.

The second reference by Douthit is a retrospective review of 46 fractures treated with a volar locked plate. Excellent initial and maintenance of reduction was noted in 85% of cases, but FPL rupture occurred in 2 patients. Prominent plates and sharp screws were cited as reasons for tendon rupture.

REFERENCES:

1. Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radial fractures with a volar locking screw plate system. Int Orthop, 27:2003: 1-6. PMID:12582800 (Link to Abstract)

2. Douthit JD. Volar plating of dorsally comminuted fractures of the distal radius: a 6-year study. Am J Orthop, 34: 2005: 140-7. PMID:15828519 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Ben Taylor MD, John Badylak MD,

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(OBQ07.226) A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation? Topic

Review Topic

FIGURES: A

1. Ulnar styloid fracture
2. Open injury
3. Ipsilateral radial head fracture
4. Time to reduction
5. Severity of initial displacement

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows a lateral view of a distal radius fracture. Acceptable radiographic parameters for a healed radius in an active, healthy patient <65 years old include: radial length within 5mm of the contralateral wrist, dorsal tilt <10 degrees, intraarticular step-off of less than 2 mm, and less than 5 degree loss of radial inclination. Several factors have been associated with re-displacement following closed manipulation of a distal radius fracture: the initial displacement of the fracture (the greater the degree of displacement, particularly radial shortening), the age of the patient (older patients with osteopenic bones displace late), and the extent of metaphyseal comminution.

Ilyas and Jupiter review the classification, treatment, and operative indications for distal radius fractures in the referenced review article.

REFERENCES:

1. Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 97-104

2. Ilyas AM, Jupiter JB. Distal radius fractures--classification of treatment and indications for surgery. Orthop Clin North Am. 2007 Apr;38(2):167-73, v. Review. PMID:17560399 (Link to Abstract)

Question Authors:

Ben Taylor MD, Jan Szatkowski MD,

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(OBQ06.60) A 46-year-old woman sustains an extra-articular fracture of the distal radius and undergoes open reduction and internal fixation with a volar plate and screw construct. During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program? Topic

Review Topic

1. Greater grip strength at 6 months
2. Less wrist pain at 1 year
3. Better hand dexterity at 1 year
4. No difference in functional outcomes
5. Quicker return to work

PREFERRED RESPONSE ▶

DISCUSSION: There are no significant benefits demonstrated with formal physical therapy following distal radius fracture ORIF compared to a patient-guided home exercise program.

The reference by Wakefield and McQueen is a randomized controlled trial of 96 patients, comparing formal hand physiotherapy to a home exercise regimen. There was no difference in grip strength, pronation/supination, radial/ulnar deviation, or hand function. The authors concluded that there were no significant benefits to formal physiotherapy.

The study by Souer et al is a level I study evaluating formal therapy and patient-guided exercise program for patients who underwent ORIF of a distal radius fracture with a volar plate and screw construct. This study showed a significant decrease in wrist ROM and grip strength with formal therapy. There were no differences in arm-specific disability (DASH score) at any time point.

REFERENCES:

1. Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 105-121.

2. Wakefield AE, McQueen MM: The role of physiotherapy and clinical predictors of outcome after fracture of the distal radius. J Bone Joint Surg Br 2000;82:972-976. PMID:11041584 (Link to Abstract)

3. Souer JS, Buijze G, Ring D. A prospective randomized controlled trial comparing occupational therapy with independent exercises after volar plate fixation of a fracture of the distal part of the radius. J Bone Joint Surg Am. 2011 Oct 5;93(19):1761-6. PMID:22005860 (Link to Abstract)

Question Authors:

Ben Taylor MD, Ben Taylor MD, Michael Hughes MD,

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TAG

(OBQ06.102) Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios? Topic

Review Topic

1. Nondisplaced distal radius fracture
2. Nondisplaced Rolando fracture
3. Second metacarpal base fracture
4. Boxer's fracture
5. Nondisplaced radial styloid fracture

PREFERRED RESPONSE ▶

DISCUSSION: Rupture of the extensor pollicis longus (EPL) tendon after non operative treatment for a distal radius fracture occurs with a 0.3-3% incidence. The causes of EPL rupture include mechanical irritation, attrition, and vascular impairment leading to delayed rupture. Synovitis of the extensor carpi radialis due to repetitive use may invade the EPL tendon and lead to rupture. Recommended treatment in the pre-rupture setting includs a third dorsal compartment release with or without an extensor retinacular patch graft. Palmaris longus graft or a transfer from the extensor indicis proprius to the EPL tendon are reasonable treatment options. Results of all treatments seem to be clinically satisfactory.

The referenced article by Gelb is a review of the etiology and treatment of this injury. He reviews the above discussion and findings.

REFERENCES:

1. Gelb RI: Tendon transfer for rupture of the EPL tendon. Hand Clin 1998;11:412-414. PMID:7559819 (Link to Abstract)

2. Flatt AE: The Care of the Arthritic Hand. St Louis, MO, Quality Medical Publishing, 1995, pp 209-211.

Question Authors:

Ben Taylor MD,

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(OBQ06.136) A 25-year-old female falls from her horse and injures her left wrist. There are no open wounds and the hand is neurovascularly intact. Radiographs are provided in Figures A-C. Which of the following will best acheive anatomic reduction, restore function, and prevent future degenerative changes of the wrist? Topic

Review Topic

FIGURES: A

1. Long arm cast above the elbow for 6 weeks
2. Long arm cast for 3 weeks followed by a short arm cast for 3 additional weeks
3. Closed reduction and external fixation
4. Closed reduction and percutaneous pinning
5. Open reduction internal fixation

PREFERRED RESPONSE ▶

DISCUSSION: The radiographs demonstrate an intra-articular distal radius fracture with dorsal angulation. Most importantly, there is a large dorsal articular fragment. Open reduction of this fragment is best acheived through an open approach. The choice of dorsal vs. volar approach is debatable, but most importantly the articular surface, radial height, and volar tilt must be reduced anatomically.

Yu et al reviewed 104 distal radius fractures treated with either dorsal or volar plating. There was no difference in the rate of tendon irritation or rupture between the groups. Volar plating was associated with significantly more neuropathic pain complications.

Illustrations A and B demonstrate the open reduction and internal fixation of this fracture with a dorsal plate. An additional lag screw was placed through the large dorsal fragment to acheive anatomic reduction that would be much more difficult to acheive through a traditional volar approach.

Illustrations: A

REFERENCES:

1. Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day CS.Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study. J Hand Surg Am. 2011 Jul;36(7):1135-41. PMID:21712136 (Link to Abstract)

Question Authors:

John Badylak MD, Ben Taylor MD, Ben Taylor MD, Bobby Chhabra M.D.,

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(OBQ05.195) A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. Two-point discrimination is now >10mm in these fingers. Radiographs show a well-fixed fracture in good alignment. What is the most appropriate treatment at this time? Topic

Review Topic

1. Strict elevation
2. Removal of hardware
3. Immediate carpal tunnel release
4. Carpal tunnel release if no resolution at 6-12 weeks
5. Trial of night splinting

PREFERRED RESPONSE ▶

DISCUSSION: This patient had mild median parasthesias preoperatively that have significantly worsened postoperatively. Immediate carpal tunnel release is the most appropriate next step in treatment.

Mack et al reported on ten cases of acute carpal tunnel syndrome (ACTS) and six cases of nerve contusion in patients with acute median neuropathy associated with blunt wrist trauma. The patients with ACTS initially had normal sensation and subsequently developed objective sensory loss (2-point discrimination greater than 15 mm) in the median nerve distribution associated with severe wrist pain. In contrast, patients with nerve contusion injuries had immediate sensory loss and symptoms were nonprogressive. Four of five patients with ACTS who underwent carpal tunnel release within 40 hours of the onset of numbness had normal 2-point discrimination within 96 hours. Neuropathy, secondary to nerve contusion without coexisting ACTS, may be treated initially by observation.

Ford et al reported of five cases of ACTS. Four with delayed treatment had poor outcomes while the one patient with early CTR had full recovery. All patients with ACTS had increasing and severe pain in the wrist with parasthesia and impaired sensation in the median distribuation. These symptoms initially weren’t present after wrist trauma, but developed rapidly in the next few hours.

REFERENCES:

1. Ford DJ, Ali MS. Acute carpal tunnel syndrome. Complications of delayed decompression. J Bone Joint Surg Br. 1986 Nov;68(5):758-9. PMID:3782239 (Link to Abstract)

2. Mack GR, McPherson SA, Lutz RB. Acute median neuropathy after wrist trauma. The role of emergent carpal tunnel release. Clin Orthop Relat Res. 1994 Mar;(300):141-6. PMID:8131326 (Link to Abstract)

3. Schnetzler KA. Acute carpal tunnel syndrome. J Am Acad Orthop Surg. 2008 May;16(5):276-82. PMID:18460688 (Link to Abstract)

Question Authors:

Doug Nowak MD, Derek Moore, Patrick McCulloch MD,

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(OBQ04.233) A 32-year-old ballet dancer sustains a distal radius fracture, and is subsequently closed reduced and casted. She presents 11 months later with the radiograph seen in Figure A, complaining of significant wrist pain. What is the appropriate surgical treatment at this time? Topic

Review Topic

FIGURES: A

1. Distal radius corrective osteotomy
2. Total wrist arthrodesis
3. Proximal row carpectomy
4. Scaphoid excision and four corner fusion
5. Interposition arthroplasty

PREFERRED RESPONSE ▶

DISCUSSION: The lateral wrist radiograph in Figure A shows significant dorsal angulation of the distal radius with a maintained joint space. The most appropriate surgical treatment for this patient would include corrective osteotomy of the distal radius, as there is no evidence of degenerative changes. If degenerative changes would be present, a salvage procedure such as total wrist arthrodesis would become an option.

The referenced article by Fernandez recommended distal radius corrective osteotomy with bone grafting and internal fixation for the following indications: 1) manually active patients who had a symptomatic extra-articular malunion of the distal end of the radius causing angulation of more than 25 to 30 degrees in either the frontal or sagittal plane without significant degenerative changes in the wrist joint (such as narrowing of the joint space, intra-articular incongruency, subchondral sclerosis, and osteophytic reaction) and in whom it was thought that the result of either a Darrach procedure or shortening osteotomy of the ulna would be uncertain because the deformity of the radius would not be corrected, and 2) patients who wished to have the deformity corrected even though they had adequate function of the wrist.

REFERENCES:

1. Fernandez DL. Correction of post-traumatic wrist deformity in adults by osteotomy, bone-grafting, and internal fixation. J Bone Joint Surg Am. 1982 Oct;64(8):1164-78. PMID:6752150 (Link to Abstract)

Question Authors:

Ben Taylor MD, Jan Szatkowski MD, John Badylak MD,

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$http://upload.orthobullets.com/cases/1341/paul frac.jpg$	rt radius communited fracture (C1341) General - Treatment Consult - Distal Radius Fractures HPI - fall while playing cricket. open reduction internal fixation or k wiring with external fixators.additin...	11/30/2012 321 responses 4
$http://upload.orthobullets.com/cases/1343/mtten wrist lon frac.jpg$	communited radius (C1343) General - Treatment Consult - Distal Radius Fractures HPI - pain inabilty to move rt wrist after fall open reduction internal fixation or external fixators	12/4/2012 40 responses
	radius frac (C1351) General - Treatment Consult - Distal Radius Fractures HPI - case of radius farcture seen a week after surgery for a second opinion is there volar instability alon with dorsal tilt and need a redo	12/8/2012 33 responses 5
	Distal radius fracture with bone loss and loss of extensor tendons of forearm (C1353) Trauma - Treatment Consult - Distal Radius Fractures HPI - History of RTA,with extensive soft tissue injury on extensor compartment of fore... What is the best option	12/9/2012 141 responses 5
$http://upload.orthobullets.com/cases/1378/ram 1mth frac.jpg$ $http://upload.orthobullets.com/cases/1378/ram 1mth frac1.jpg$	distal radius fracture (C1378) General - Treatment Consult - Distal Radius Fractures HPI - h/o fall 1 month ago.slipped on snow.patient has very minimal pain at present.do... orif with bone grafting or allow healing	1/8/2013 46 responses

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	Distal Radius Fx ORIF with Volar Approach - Miami Hand Center Hand - Surgical Techniques - Distal Radius Fractures Distal Radius Fx ORIF with Volar Approach Miami Hand Center, MiamiHandCenter.com...	8/28/2012 271 views 3
	MIS Distal Radius Fixation with Volar Locking Plate - Dr. Ruggiero Hand - Surgical Techniques - Distal Radius Fractures Distal Radius Fixation with Volar Locking Plate by a Minimally Invasive Approach...	8/28/2012 153 views 3
	Extensor Tendon Repair using Palmaris Longus - Dr. Trumble General - Treatment Consult - Distal Radius Fractures In this patient there is extensor tendon rupture due to K wire irritation follow...	8/12/2012 177 views 4

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ABOS II: Distal Radius Fractures

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. 2007 Jul;89(7):1424-31. PMID:17606778 (Link to Abstract)
Souer JS, Buijze G, Ring D. A prospective randomized controlled trial comparing occupational therapy with independent exercises after volar plate fixation of a fracture of the distal part of the radius. J Bone Joint Surg Am. 2011 Oct 5;93(19):1761-6. PMID:22005860 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Dyer G, Lozano-Calderon S, Gannon C, Baratz M, Ring D. Predictors of acute carpal tunnel syndrome associated with fracture of the distal radius. J Hand Surg Am. 2008 Oct;33(8):1309-13 PMID:18929193 (Link to Abstract)
Wakefield AE, McQueen MM: The role of physiotherapy and clinical predictors of outcome after fracture of the distal radius. J Bone Joint Surg Br 2000;82:972-976. PMID:11041584 (Link to Abstract)

Level of Evidence 4 (Case Series)

Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am. 2004 Sep;86-A(9):1900-8. PMID:15342751 (Link to Abstract)
Besse JL, Gadeyne S, Galand-Desmé S, Lerat JL, Moyen B. Effect of vitamin C on prevention of complex regional pain syndrome type I in foot and ankle surgery. Foot Ankle Surg. 2009;15(4):179-82. Epub 2009 Apr 5. PMID:19840748 (Link to Abstract)
Magnussen PA, Harvey FJ, Tonkin MA. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon. J Bone Joint Surg Br. 1990 Sep;72(5):881-3 PMID:2211775 (Link to Abstract)
Hove LM. Delayed rupture of the thumb extensor tendon. A 5-year study of 18 consecutive cases. Acta Orthop Scand. 1994 Apr;65(2):199-203 PMID:8197857 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Taylor KF, Parks BG, Segalman KA. Biomechanical stability of a fixed-angle volar plate versus fragment-specific fixation system: cyclic testing in a C2-type distal radius cadaver fracture model. J Hand Surg Am. 2006 Mar;31(3):373-81. PMID:16516730 (Link to Abstract)
Schnetzler KA. Acute carpal tunnel syndrome. J Am Acad Orthop Surg. 2008 May;16(5):276-82. PMID:18460688 (Link to Abstract)
Gelb RI: Tendon transfer for rupture of the EPL tendon. Hand Clin 1998;11:412-414. PMID:7559819 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 97-104
Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 105-121.
Flatt AE: The Care of the Arthritic Hand. St Louis, MO, Quality Medical Publishing, 1995, pp 209-211.

Undefined

Kim JK, Koh YD, Do NH. Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radial fracture? J Bone Joint Surg Am. 2010 Jan;92(1):1-6. PMID:20048089 (Link to Abstract)
af Ekenstam F, Jakobsson OP, Wadin K. Repair of the triangular ligament in Colles' fracture. No effect in a prospective randomized study. Acta Orthop Scand.1989 Aug;60(4):393-6. PMID:2683564 (Link to Abstract)
Clinical Practice Guideline on the Treatment of Carpal Tunnel Syndrome. Rosemont, IL, American Academy of Orthopaedic Surgeons, September, 2008.
Jupiter JB, Fernandez DL: Complications following distal radial fractures. J Bone Joint Surg Am 2001;83:1244-1265 PMID:12064104 (Link to Abstract)
Hove LM: Delayed rupture of the thumb extensor tendon: A 5-year study of 18 consecutive cases. Acta Orthop Scand 1994;65:199-203 PMID:8197857 (Link to Abstract)
Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radial fractures with a volar locking screw plate system. Int Orthop, 27:2003: 1-6. PMID:12582800 (Link to Abstract)
Douthit JD. Volar plating of dorsally comminuted fractures of the distal radius: a 6-year study. Am J Orthop, 34: 2005: 140-7. PMID:15828519 (Link to Abstract)
Ilyas AM, Jupiter JB. Distal radius fractures--classification of treatment and indications for surgery. Orthop Clin North Am. 2007 Apr;38(2):167-73, v. Review. PMID:17560399 (Link to Abstract)
Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day CS.Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study. J Hand Surg Am. 2011 Jul;36(7):1135-41. PMID:21712136 (Link to Abstract)
Ford DJ, Ali MS. Acute carpal tunnel syndrome. Complications of delayed decompression. J Bone Joint Surg Br. 1986 Nov;68(5):758-9. PMID:3782239 (Link to Abstract)
Mack GR, McPherson SA, Lutz RB. Acute median neuropathy after wrist trauma. The role of emergent carpal tunnel release. Clin Orthop Relat Res. 1994 Mar;(300):141-6. PMID:8131326 (Link to Abstract)
Schnetzler KA. Acute carpal tunnel syndrome. J Am Acad Orthop Surg. 2008 May;16(5):276-82. PMID:18460688 (Link to Abstract)
Fernandez DL. Correction of post-traumatic wrist deformity in adults by osteotomy, bone-grafting, and internal fixation. J Bone Joint Surg Am. 1982 Oct;64(8):1164-78. PMID:6752150 (Link to Abstract)

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Distal Radius Fractures

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